How long should dual antiplatelet therapy be continued after PCI?

Takeaway

• Long-term dual anti-platelet therapy (DAPT) was associated with a higher risk for major bleeding and mortality, and standard-term DAPT was associated with increased risk for any bleeding compared with short-term DAPT (clopidogrel) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).
• Standard-term DAPT showed similar safety and efficacy compared with short-term DAPT.

Why this matters

• The recommendation for ≥12 months of DAPT after PCI with DES has received scrutiny by several randomised controlled trials, which proved nonsuperiority vs 3-6 months of DAPT.
• Findings suggest it might be reasonable to apply long-term DAPT to a narrower spectrum of patients

Study design

• 17 randomised controlled trials (RCTs; n=46,864) met eligibility criteria after a search across electronic database.
• Efficacy outcomes: all-cause mortality, cardiac and non-cardiac mortality, myocardial infarction (MI), stroke, stent thrombosis and adverse events.
• Safety outcomes: major and any bleeding.
• Funding: Major Science and Technology Project of Hunan Province; others.

Key results

• Long- vs short-term DAPT was associated with increased risk for:
  • all-cause mortality (OR, 1.18; 95% CI, 0.93-1.49),
  • cardiac death (OR, 1.28; 95% CI, 0.88-1.86),
  • non-cardiac death (OR, 1.63; 95% CI, 1.03-2.59),
  • major bleeding (OR, 1.78; 95% CI, 1.27-2.49) and
  • any bleeding (OR, 2.13; 95% CI, 1.46-3.10).
• Standard- vs short-term DAPT was associated with a higher risk for any bleeding (OR, 1.39; 95% CI, 1.01-1.92).
• Long- and standard- vs short-term DAPT did not differ in MI, stroke, stent thrombosis and adverse events.
• In the subgroup analysis, among patients implanted with newer-generation DES, long- vs short-term DAPT showed a higher risk for:
  • all-cause mortality (OR, 1.99; 95% CI, 1.04-3.81),
  • major bleeding (OR, 1.88; 95% CI, 1.03-3.45) and
  • any bleeding (OR, 1.79; 95% CI, 1.28-2.50). 

Limitations

• Duration of DAPT was evaluated based on clopidogrel only.
• Analyses of outcomes were performed from different trials with pooled definitions.